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									        Bixby Program in Population & Reproductive Health, March 2007

             The Challenge of
Reproductive Health in Complex Emergencies

  Stephen Tomlin, VP Program Policy & Planning, International Medical Corps

1985:     5
1992:    17
1999:    34
2006:    38
• Civil conflict         • Massive economic
• Weak or non-existent     dislocation
  central government     • Food insecurity leading
                           to famine
• Mass population
Complex Emergency Settings

             • People in need of
               humanitarian assistance:
                – 1989: 36 million
                – 1996: 50 million
                – 2004: 39 million

             • Many more IDPs:
               – 25 m. IDPs / 49 countries
               – 14 m. Refugees
   Since 1984…

…providing health care through
training / developing local capacity

                                       …supporting health care
                                       delivery through logistic
                                       management systems
    IMC Relief, Recovery,
    & Development Programs - 2007
•   Afghanistan        •   Kenya
•   Azerbaijan         •   Liberia
•   Burundi            •   Pakistan
•   Chad               •   Sierra Leone
•   DR Congo           •   Somalia
•   Eritrea            •   northern Sudan (Darfur)
•   Ethiopia           •   southern Sudan
•   Indonesia          •   Sri Lanka
•   Ingushetia/Chechnya•   Uganda
•   Iraq               •   USA (Louisiana)
Humanitarian Space Shrinking

              View from IMC driver’s seat, Darfur, Feb 28 ‘07
    Humanitarian Space is Shrinking
1997-2005                     2006:
• Over 9 year period:           83 aid workers killed
  major acts of violence        78 aid workers wounded
  against aid workers doubled   52 aid workers kidnapped
• 408 acts of major violence
  947 victims                 • #1. Afghanistan (26 killed)
                                #2. Sri Lanka (23 killed)
  434 fatalities                #3. Sudan (15 killed)

• Today, most victims
  deliberately targeted, w/        • Sudan accounted for 40% of
  political targeting on the rise.   incidents
  Approach to Security Management
The Evolving Security Environment
    - Greater exposure, new threats, diminishing respect for IHL
The Acceptance Strategy
    - Establishing, and then fiercely defending, relationships with
             local actors
    - Built on trust, transparency, and predictability…as
             perceived by locals
    - Protection and Deterrence strategies also employed, but
     - At IMC, underpinned by strong security management policy and
   - Humanitarians do not themselves carry weapons
   - With some noteworthy exceptions, they do not employ or
           accept armed protection in the course of their work
Levels of Activity
   Ministry of Health                             For profit
   Tertiary referral       Charitable                          doctors
       hospital             hospitals
                             Charitable Primary doctors
                              hospitals Health doctorsdoctors
    Provincial Hosp
                        Charitable                             doctors
     District Hosp       hospitals        clinics

     Health Center          Health Post
Community Health Workers                clinics
Community-based Relief & Recovery

Health                     Recovery &
• Under-5 Child Health       Development
• Reproductive Health      • Mobilization
• Immunization (EPI)       • Psychosocial
• Nutrition                • Water & Sanitation
• Mental Health            • Livelihoods
                           • Micro-finance

Uganda: Therapeutic & Supplementary Feeding Programs
  What is Reproductive Health?

• RH is a state of complete physical, mental and
  social well-being, and not merely the absence of
  disease or infirmity, in all matters relating to the
  reproductive system and its functions and

• RH implies that people are able to have a
  satisfying and safe sex life and that they have
  capability to reproduce and the freedom to
  decide, if, when and how often to do so.
RH Rights Include:

• The right to health in general
• The right to reproductive choice
• The right to RH services
• The right of men and women to marry
  and found a family
• The right of the family to have special
• Special right in relation to motherhood
  and childhood
Cycle of Reproductive Ill-Health

   Source: WHO. Reproductive Health during Conflict and Displacement: A Guide for Program Managers. Geneva: World Health
   Organization, Department of Reproductive Health and Research, 2000.                                                     5
Life Span Profile of Discrimination Against Women

      Source: WHO. Reproductive Health during Conflict and Displacement: A Guide for Program Managers. Geneva: World Health
      Organization, Department of Reproductive Health and Research, 2000.                                                     7
Key Components of RH Program
• Gender-based violence
  prevention and response
• Safe motherhood
• STIs, including HIV/AIDS
• Family planning
                             IMC MCH Clinic, Liberia

New Orleans
Iraq – Vulnerable Populations
                          Displacement Trends, Iraq


Displaced Families

                     100,000                    MoDM
                                                IOM inc. KRG




                           2/2/06   3/24/06   5/13/06          7/2/06     8/21/06   10/10/06   11/29/06   1/18/07   3/9/07

  Gender-based Violence

• Sexual violence           • Emotional,
   – Rape, attempted rape     psychological and social
   – Sexual coercion          abuse
   – Sexual harassment         – Humiliation

• Physical violence         • Harmful traditional
   – Domestic violence,       practices
     spouse beating            – Female genital cutting
   – Assault                     (FGC)
                               – Early, forced marriage
  Factors Contributing to GBV
• Lack of police protection and lawlessness
• Coercion around food and other ration distributions
• Insecure living quarters; distance women have to
  travel to collect firewood, to latrines, etc.
• Political motivation
• Collapse of traditional family and societal support
• Strains of life when displaced from home

    GBV Prevention and Response (1)
•   Prevention                        •   Policy/management
     – Involve refugee women              – Train and monitor authorities
     – Public information                    and staff to reduce sexual
     – Camp design, location                 extortion

     – Food and other distributions       – Ensure proper documentation
                                            for women
•   Protection
                                          – Increase women protection
     – Ensure physical safety
•   Psychosocial
                                          – Increase visibility of problem
     – Counseling
                                            and seriousness of response
     – Support groups
                                          – Document cases, care and
     – Community education to               other responses
       decrease stigma                •   Legal
     – Justice/legal support                                                 7
      GBV Prevention and Response (2)
•   Medical
     – Trauma care
    – Emergency
    – Pregnancy testing
    – Voluntary testing for
    – Voluntary testing and
      treatment for STIs
    – Awareness and
      sensitivity of staff
    – Confidentiality
    – Referral for legal, social
      and other services
                                   International Women’s Day, Refugee Camp, Chad
   Maternal Morbidity and Mortality

Uncomplicated pregnancy,                 Well
delivery, postpartum period

                              short and long-term morbidity

                                         near miss

     Life Threatening
       Complication                        Death
   Complications are Unpredictable
• At least 15% of pregnant
  women in any population are
  expected to have life-
  threatening complications.
                                    IMC Trained Midwife, Darfur
• Cannot predict or prevent
  complications: any delivery
  can become complicated and
  require emergency intervention

• Best practice: reduce delays
  through training in recognition
  danger signs and referral to
  health facility
  Perinatal Deaths
• 28 weeks gestation            • Leading causes of
  through 7 days after            Perinatal Death
  birth                           –   Syphilis
                                  –   Infection (sepsis)
• 7.6 million perinatal           –   Asphyxia
  deaths/year                     –   Trauma
     4.3 million stillbirths;     –   Neonatal tetanus
     3.3 early neonatal           – Complications of preterm
     deaths                         delivery
Key Strategies for Preventing Maternal
and Perinatal Deaths
• Prevent unwanted
  pregnancies through family
• Early recognition of
  complications, with referral
• Access to skilled
  attendants and emergency
  obstetric care
• Management of post-
  abortion complications
• Breastfeeding support
• Essential newborn care
                                 Rabia Balki Hospital for Women, Kabul
 Antenatal care
• Health assessment
• Detection and management of
• Maintenance of maternal nutrition
• Health education
• Health promotion interventions
                                       TBA Training, Pakistan
  such as tetanus toxoid (TT)
  vaccinations, folic acid and
  ferrous sulfate supplements,
  malaria prophylaxis or
  presumptive treatment, and
  testing for syphilis, depending on
  the context
Training TBAs in Darfur
  Intrapartum/Delivery Care
• 100% of women who
  develop a complication
  should be treated by a
  skilled attendant in an
  emergency obstetric care
• Basic emergency obstetric
  care (equipped health
• Comprehensive emergency
  obstetric care (referral
• Transport for deliveries
  outside an equipped health
• Support for breastfeeding    Sudanese mother, Chad
Rabia Balki Hospital for Women, Kabul
Postpartum Care
• Monitor for danger signs
  and refer
• Postpartum visit
• Education
• Newborn weighing and
• Support for breastfeeding
• Promoting health of
  newborn, including thermal
  protection, eye care, cord
  care, vaccinations
• Postpartum family planning
    Sexually Transmitted Infections (STIs)

•   Trichomoniasis
•   HIV
•   Chancroid
•   Hepatitis B
•   Genital Warts
•   Herpes
                                       Elders meeting, NWFP, Pakistan
•   Gonorrhea        In women between 15 and 44 years of age,
                     the morbidity and mortality associated with
•   Chlamydia        STIs, not including HIV, are second only to
                     maternal causes.
 Regional HIV / AIDS
• Worldwide
  – 17.7 million
  – 48% Women
• Sub-Sahara
  – 13.3 million
  – 59 % Women
• South & South
  East Asia
  – 2.2 million
  – 29% Women
• Caribbean
  – 120,000
  – 50% Women          Community Mobilizers, Kibera slum, Nairobi
Kibera slum, population 800,000
  Family Planning
• Saves women’s lives
   – Avoids unsafe abortion
   – Limits exposure to the health risks of
     pregnancy and childbirth
   – Limits births to the healthiest ages
   – Limits the number of births
                                              Effective Programs:
• Saves children’s lives
• Offers women more choices                   Coordinated
                                              Robust logistic systems
• Encourages adoption of safer sexual         Extensive training & education
  behavior                                    Discrete
  Gender Inequality
Women’s autonomy and
 authority are
 traqditionally limited


                Livelihoods & Micro-Finance
IMC Training Highly Valued

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